Pyelonephritis is the most common serious medical problem that complicates pregnancy. Infection is more common after midpregnancy, and is usually caused by bacteria ascending from the lower tract. Escheria coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteraemia- A common finding is thermoregulatory instability, with very high spiking fevers sometimes followed by hypothermia- Almost 95% of women will be afebrile by 72 hours. However, it is common to see continued fever spikes up until that time- Thus, further evaluation is not indicated unless clinical improvement at 48-71 hours is lacking. If this is the case, the patient should be evaluated for urinary tract obstruction, urinary calculi and an intrarenal or perinephric abscess. Ultrasonography, plain radiography, and modified intravenous pyelography are all acceptable methods, depending on the clinical setting.

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. The intermittent vaginal bleeding and the requirement for manual removal of the placenta suggest endometritis as the most possible diagnosis.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.

HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.

The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.

Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.

Chromosomal abnormalities are the most common cause of first trimester miscarriage and are detected in 50-85% of pregnancy tissue specimens after spontaneous miscarriage.

The next best line of management is immediate delivery via Caesarean section ( C section).

This is because of the change in cardiotocography (CTG). The pattern became much more severe with a virtual lack of short-term variability and prolonged decelerations. These changes indicate the necessity for an immediate C section as the cervix is not fully dilated.

As immediate delivery is indicated, another pH assessment is unnecessary as it would delay delivery and increase the likelihood of fetal hypoxia.

Delivery by ventose, in a primigravida where the cervix is only 8cm dilated is not indicated as it would allow the labour to proceed or augmenting with Syntocinon.

Invasive procedures as fetal scalp blood sampling or internal electrode and episiotomy increase vertical transmission of HCV, especially in patients with positive HCV RNA virus load at delivery that is why it should be avoided.

Dizygotic twin pregnancies are known to increase with age of the mother. Naturally conceived twins are thought to occur in a 0.3% rate in women under 25 years, 1.4% between 25 and 34, 3% between 34 and 39, and 4.1% in women in their 40s or over. We also know that at least 50% of all twin pregnancies are conceived through ART and that this proportion is probably higher for women in their 40s.

All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a foetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the foetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder.

In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation.

An ultrasonography is performed for confirmation, as well as for the evaluation of maternal pelvis, fetal size and viability in cases were breech presentation is suspected on manual examination. As there is a chance for spontaneous correction of breech presentation into cephalic during 36 to 37 weeks, this should be considered in every future visit. The chances for spontaneous version reduces to 25% if breech position persists beyond this period of time.

It an external cephalic version should be offered to all women with breech presentation, provided there are no contraindications or indication for cesarean delivery due to other reasons.

Penicillin is the treatment of choice for treating syphilis. For treatment of syphilis during pregnancy, no proven alternatives to penicillin exist. Treatment guidelines recommend desensitization in penicillin-allergic pregnant women, followed by treatment with penicillin. Syphilis in pregnancy is associated with mental retardation, stillbirth and sudden infant death syndrome; therefore it should be treated promptly.

– Data are insufficient to recommend ceftriaxone for treatment of maternal infection and prevention of congenital syphilis.
– Erythromycin and azithromycin should not be used, because neither reliably cures maternal infection or treats an infected foetus.
– Tetracycline and doxycycline are contraindicated in pregnancy and ceftriaxone is much less effective than penicillin.

The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.

A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.

Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.

Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.

Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.

Fetal lie refers to the relationship between the long axis of the foetus relative to the long axis of the mother. If the foetus and maternal column are parallel (on the same long axis), the lie is termed vertical or longitudinal lie.

Fetal presentation means, the part of the foetus which is overlying the maternal pelvic inlet.

Position is the positioning of the body of a prenatal foetus in the uterus. It will change as the foetus develops. This is a description of the relation of the presenting part of the foetus to the maternal pelvis. In the case of a longitudinal lie with a vertex presentation, the occiput of the fetal calvarium is the landmark used to describe the position. When the occiput is facing the maternal pubic symphysis, the position is termed direct occiput anterior.

Fetal attitude is defined as the relation of the various parts of the foetus to each other. In the normal attitude, the foetus is in universal flexion. The anatomic explanation for this posture is that it enables the foetus to occupy the least amount of space in the intrauterine cavity. The fetal attitude is extremely difficult, if not impossible, to assess without the help of an ultrasound examination.

Despite the fact that this question includes many true-false options, the knowledge examined is particularly essential in the treatment of women who have genital herpes.
It answers many of the questions that such women have regarding the disease, how it spreads, how it may be controlled, and how it affects an unborn or recently born child.
All of these issues must be addressed in a counselling question.
Currently, the most prevalent type of genital herpes is type 1, while in the past, type 2 was more common, as confirmed by serology testing.
Type 2 illness is nearly always contracted through sexual contact, but it can go undetected for years.
Acyclovir can be taken during pregnancy, and there are particular reasons for its usage.
Neonatal herpes is most usually diagnosed when the newborn has no cutaneous lesions, and past genital herpes in the mother is protective against neonatal infection, although not always.
Where the genital infection is the initial sign of the disease rather than a relapse of earlier disease, neonatal herpes is far more frequent.
Many patients and doctors are unaware that, while the original infection might be deadly, it is usually asymptomatic.
This explains how the illness spreads between sexual partners when neither has had any previous symptoms of the disease.

This is a case of a pregnant patient having vaginal bleeding. Given the patient’s presentation, the most likely cause of this patient’s antepartum haemorrhage is placenta praevia. The haemorrhage is unlikely to be due to a vasa praevia because a loss of 300mL would usually cause fetal distress or death, neither of which has occurred. Cervical malignancy is also unlikely as it typically would not have bleeding of this magnitude. A possible diagnosis would be a small placental abruption as it would fit with the lack of uterine tenderness and normal uterine size.

For the immediate management of this patient, induction of labour is contraindicated before the placental site has been confirmed. Also, induction should not be performed when the gestation is only at 33 weeks, especially after an episode of a small antepartum haemorrhage. An ultrasound examination of the uterus is appropriate as it would define whether a placenta praevia is present and its grade. It would also show whether there is any evidence of an intrauterine clot associated with placental abruption from a normally situated placenta.

If a placenta praevia is diagnosed by ultrasound, a pelvic examination under anaesthesia may be a part of the subsequent care, if it is felt that vaginal delivery might be possible. Usually it would be possible if the placenta praevia is grade 1 or grade 2 anterior in type. However, pelvic exam at this stage is certainly not the next step in care, and is rarely used in current clinical care.

A Papanicolaou (Pap) smear will be necessary at some time in the near future, but would not be helpful in the care of this patient currently.

Immediate Caesarean section is not needed as the bleeding has stopped, the foetus is not in distress, and the gestation is only 33 weeks.

Fetal position and presentation is best evaluated by Leopold’s manoeuvre. It will determine which part of the foetus is in the uterine fundus.
Cullen’s sign is found in ruptured ectopic pregnancy characterised by bruising and oedema of the periumbilical region.
Mauriceau-Smelli-Veit manoeuvre is done during a breech delivery.

Cholestasis of pregnancy is associated with increased fetal morbidity and mortality and should be treated actively. The significance attached to pruritus in pregnancy is often minimal, but it is a cardinal symptom of cholestasis of pregnancy, which may have no other clinical features.

This patient presents with signs and symptoms similar to clinical features of placental abruption.

Any trauma during the last trimester of pregnancy could be dangerous to both mother and fetus. By force of deceleration, motor vehicle accidents can result in placental separation. Also when subjected to strong acceleration-deceleration forces such as those during a motor vehicle crash uterus is thought to slightly change its shape. Since the placenta is not elastic and amniotic fluid is not compressible, such uterine distortion caused due to acceleration-deceleration or direct trauma will result in abruptio placentae due to shear stress at the utero-placental interface.

A painful, tender uterus which is often contracting is characteristic of placental abruption and the condition will lead to maternal hypovolemic hypotension and consequent fetal distress which is presented as fetal bradycardia and repetitive late decelerations. Vaginal bleeding, abdominal pain, contractions, uterine rigidity with tenderness, and a nonreassuring fetal heart rate (FHR) tracing are the clinical features diagnostic of abruption. However, a significant abruption can occasionally be asymptomatic or associated with minimal maternal symptoms in the absence of vaginal bleeding. Therefore the amount of vaginal bleeding is not always an appropriate indicator to the severity of placental abruption, this is because, in cases bleeding could be very severe or it may be concealed in the form of a hematoma in between the uterine wall and the placenta.

Sharp or blunt abdominal trauma can lead to uterine rupture or penetrating injury, since there is no reported abdominal trauma to the patient, uterine rupture is less likely to happen in this case. Severe abdominal pain with tenderness, cessation of contractions and loss of uterine tone are the most common symptoms characteristic of Uterine rupture. It will also be associated with mild to moderate vaginal bleeding along with fetal bradycardia or loss of heart sound. In this case uterus will be less tense and tender in comparison to placental abruption

Symptoms like low blood pressure, tachycardia and fetal bradycardia can be justified by ruptured spleen and liver laceration, but not the tense, tender and contracting uterus.

The diagnosis of placenta previa cannot be considered with the given clinical picture as it presents with sudden, painless bleeding of bright red blood and there will not be any uterine tenderness.

The syndrome with which the woman was diagnosed is an autoimmune, hypercoagulable state which most possibly was the reason of her previous miscarriages. This is the reason why she should be on aspirin and heparin in order to prevent any future miscarriage.

The given case can be diagnosed as round ligament pain, which is common during pregnancy. This happens as a result to the stretching of round ligament in pelvis to occupy the growing uterus. The round ligament pain usually gets worse with movements or straining and will be relieved by rest or warm application.

As the abdominal examination of patient is unremarkable, conditions like ovarian cyst rupture, ectopic pregnancy and intestinal obstruction are a very unlikely to be the diagnosis.

The presentation is antepartum haemorrhage. Ultrasound should be performed to find the reason for bleeding and assess the fetal well being.

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

Extreme headache, vision defects, such as blurring of the eyes, rib pain, sudden swelling of the face, hands or feet are all consistent with pre-eclampsia. Women with the mentioned symptoms should have their blood pressure checked immediately. They should also be checked for proteinuria. Diarrhoea is not related to pre-eclampsia. Pruritus would be more related to pregnancy cholestasis. Meanwhile, bruising and abnormal LFTs are common in complicated pre-eclampsia but not in an uncomplicated one.

Neural tube defects (NTDs) are common complex congenital malformations resulting from failure of the neural tube closure during embryogenesis. It is established that folic acid supplementation decreases the prevalence of NTDs, which has led to national public health policies regarding folic acid.

Neural tube defects (NTD) were 43% more common in Indigenous than in non-Indigenous infants in Western Australia in the 1980s, and there has been a fall in NTD overall in Western Australia since promotion of folate and voluntary fortification of food has occurred.

Women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.

Women planning pregnancy might be exposed to medications with known antifolate activities affecting different parts of the folic acid metabolic cascade. A relatively large number of epidemiologic studies have shown an increased risk of NTDs among babies exposed in early gestation to antiepileptic drugs (carbamazepine, valproate, barbiturates), sulphonamides, or methotrexate. Hence, whenever women use these medications, or have used them near conception, they should take 5 mg/d of folic acid until the end of the first trimester of pregnancy.

Immediate treatment for infants with suspected meconium aspiration syndrome is to clear/suction the airway. Intubation and tracheal toileting have remained a matter of debate till the most recent times. All neonates at risk of MAS who show respiratory distress should be admitted to a neonatal intensive care unit and monitored closely. The treatment is mainly supportive and aims to correct hypoxemia and acidosis with the maintenance of optimal temperature and blood pressure.

There is a significant increase in oxygen demand during pregnancy due to a 15% increase in the metabolic rate and a 20% increased consumption of oxygen. There is a 40–50% increase in minute ventilation, mostly due to an increase in tidal volume, rather than in the respiratory rate. In a healthy, young human adult, tidal volume is approximately 500 mL per inspiration

Decreased pregnancy-associated plasma protein (PAPP-A) in the first trimester of pregnancy is an indication to carry out further diagnostic testing for Down syndrome.

Antenatal tests available for screening Down syndrome are divided into two types:
– Screening tests includes maternal serum screening and ultrasound which are safe to conduct with relatively low predictive values.
– Diagnostic tests like chorionic villous sampling and amniocentesis are confirmative but carries higher risk of miscarriage as 1 in 100 and 1 in 200 respectively.

a) Serum screening tests for Down syndrome during first-trimester includes:
1. Pregnancy-associated plasma protein (PAPP-A) will be decreased in case of Down syndrome.
2. Free ß-human chorionic gonadotropin (HCG) will be increased in cases of Down syndrome.
If these screening tests are combined with first-trimester ultrasound nuchal translucency, it is found to be more accurate than doing only one of these tests.

b) Second-trimester serum screening tests for identifying Down syndrome:
1.Alpha-fetoprotein will be decreased.
2.Unconjugated oestriol will be decreased.
3.Free ß-HCG will be increased
4.Inhibin A will be increased.
These tests combined with maternal age and ultrasound results will provide more accurate predictive values.

When the palpated uterine size is in discrepancy with the expected size based on the duration of amenorrhoea, it can have several causes including reduced fluid volume or fetal growth (both of which are more common when there is fetal malformation), or miscalculated age of gestation as a result of wrong dates or actual ovulation occurring at a later date than expected. Reduced fluid volume and fetal growth are the most likely aetiologies during the third trimester of pregnancy, unlike in this patient at 20 weeks age of gestation.

Premature rupture of membranes is less likely the cause when there is negative vaginal fluid loss like this patient.

The most likely cause in this case is that ovulation did not occur as expected, especially when the patient ceased her OCPs during this period. In some instances, ovulation can occur 2 weeks later in about 50% of women, 6 weeks later in 90%, and may still not occur 12 months later in 1% of women.

The other listed statements are unlikely to explain the discrepancies in dates and the observed uterine size in this patient.

If the patient already has immunity (IgG positive) and if maternal rubella infection is the cause of the current symptoms (initial lgG and IgM negative, but IgM positive on a second sample 2-3 weeks later), amniocentesis may be required to confirm fetal infection.
Ultrasound may reveal growth limitation in late pregnancy, but a fetal congenital defect is rare when the infection begins at 10 weeks of pregnancy, and ultrasound testing at 12 weeks of pregnancy is unlikely to detect abnormalities, while it may discover one from 18-20 weeks. Given the well-known deleterious fetal effects of rubella infection in early pregnancy, gamma-globulin is unlikely to be beneficial at this point in the infective process, and pregnancy termination would certainly be considered by some individuals.
On the basis of prenatal rubella infection, this would not be recommended unless the infection was shown to have occurred.

According to the laboratory reports, patient has developed urinary tract infection and should be treated with one week course of oral antibiotics.
As the patient is pregnant, antibiotics like cephalexin, co-amoxiclav and nitrofurantoin must be considered as these are safe during pregnancy.

Due to this Patient’s allergic history to penicillin, cephalexin can be considered as the best option. Risk of cross allergy would have been higher if the patient had any history of anaphylactic reactions to penicillin.

In Australia, Amoxicillin is not recommended to treat UTI due to resistance.Tetracyclines also should be avoided during pregnancy due to its teratogenic property.

Bradycardia of <100 bpm for more than 5 minutes or <80 for more than 3 minutes is always considered abnormal. The given case describes fetal bradycardia detected on fetal heart auscultation and the most common causes for severe bradycardia are prolonged cord compression, cord prolapse, epidural and spinal anesthesia, maternal seizures and rapid fetal descent. Immediate management including identification of any reversible causes for the abnormality and initiation of appropriate actions like maternal repositioning, correction of maternal  hypotension, rehydration with  intravenous fluid,  cessation of oxytocin, tocolysis for excessive uterine activity, and initiation or maintenance of continuous CTG should be considered in clinical situations where abnormal fetal heart rate patterns are noticed. Consideration of further fetal evaluation and delivery if a significant abnormality persists are very important. The next step in this scenario where the baby is in 1+ station, with an abnormal fetal heart rate detected on auscultation would be to perform a confirmatory cardiotocography (CTG) and if the CTG findings confirm the condition despite initial measures obtained, prompt action should be taken. Cord compression or prolapse should come on the top of the differential diagnoses list as the the mother shows normal general conditions, but since the cervix is 8 cm dilated, 100% effaced and the fetal head is already engaged, cord prolapse would be unlikely; therefore, repeating vaginal exam is not as important as confirmatory CTG. However a vaginal exam should be done, if the scenario indicates any possibility of cord prolapse, to exclude cord compression or prolapse. NOTE– In cases of severe prolonged bradycardia, immediate delivery is recommended, if the cause cannot be identified and corrected.

Amniocentesis is a prenatal procedure performed on a pregnant woman to withdraw a small amount of amniotic fluid from the sac surrounding the foetus.
The goal of amniocentesis is to examine a small amount of this fluid to obtain information about the baby, including its sex, and to detect physical abnormalities such as Down syndrome or spina bifida.
Amniocentesis is only performed on women thought to be at higher risk of delivering a child with a birth defect.

Amniocentesis is performed between 16 and 20 weeks into the pregnancy. By around this time, the developing baby is suspended in about 130ml of amniotic fluid, which the baby constantly swallows and excretes. A thin needle is used to withdraw a small amount of this fluid from the sac surrounding the foetus.

A brow presentation in a nulliparous woman is associated with high risk of obstructed labour and the need for delivery by Caesarean section.

Brow presentation occurs when the presenting part of the fetal head is the part between the orbital ridge and anterior fontanelle.

In multiparous women, the indications differ as vaginal manipulation or spontaneous flexion to a vertex presentation or extension to a face presentation can occur after full cervical dilatation.

Early fetal heart decelerations are indicative of a mild abnormality on cardiotocograph (CTG). It does not indicate obstructive labour or need for delivery by Caesarean section.

The slow descent of the fetal head can be controlled subsequently by good uterine contractions and allow for vaginal birth.

Prolonged labour can cause maternal fever, but that in isolation is not an indication for Caesarean section.

Caput and head moulding are associated with a ‘tight fit’ of the fetal head in the pelvis, but does not contraindicate vaginal birth.

Among all the antiepileptic drugs sodium valproate carries the highest teratogenicity rate. The potential congenital defects caused by sodium valproate are as below:
– Neural tube defects like spina bifida, anencephaly
– Cardiac complications like congenital ventricular septal defect, aortic stenosis, patent ductus arteriosus, aberrant pulmonary artery
– Limb defects like polydactyly were more than 5 fingers are present, oligodactyly were less than 5 fingers are present, absent fingers, overlapping toes, camptodactyly which is presented as a fixed flexion deformity of one or more proximal interphalangeal joints,split hand, ulnar or tibial hypoplasia.
– Genitourinary defects like hypospadias, renal hypoplasia, hydronephrosis, duplication of calyceal system.
– Brain anomalies like hydranencephaly, porencephaly, arachnoid cysts, cerebral atrophy, partial agenesis of corpus callosum, agenesis of septum pellucidum, lissencephaly of  medial sides of occipital lobes, Dandy-Walker anomaly
– Eye anomalies like bilateral congenital cataract, optic nerve hypoplasia, tear duct anomalies, microphthalmia, bilateral iris defects, corneal opacities.
– Respiratory tract defects like tracheomalacia, lung hypoplasia,severe laryngeal hypoplasia, abnormal lobulation of the right lung, right oligemic lung which is presented with less blood flow.
– Abdominal wall defects like omphalocele
– Skin abnormalities capillary hemangioma, aplasia cutis congenital of the scalp.

Shoulder dystocia is a complication associated with fetal macrosomia and may result in neurological dysfunction. Fetal macrosomia is generally defined as birth weight – 4,000 g. It occurs in about 10% of pregnancies and one of the most important predictors of fetal macrosomia is previous macrosomic infant(s). The recurrence rate of fetal macrosomia is above 30%. Other risk factors are maternal diabetes, multiparity, prolonged gestation, maternal obesity, excessive weight gain, male foetus, and parental stature- Not all cases of fetal macrosomia lead to shoulder dystocia and the occurrence of this complication is only 0.5%-1% of all pregnancies.

To make clinical decision regarding management of the patient, it is important to understand that there are other factors that lead to shoulder dystocia, such as the mother’s anatomy. While statistics suggest that there’s a tendency to choose elective Caesarean delivery for suspected macrosomia, it is believed that most of procedures are unnecessary, as evidence has shown the number of complications are not reduce- Also while it is logical to consider induction of labour at the 37th week of pregnancy, it is associated with increased Caesarean deliveries because of failed inductions. The recommended course of action is watchful waiting till the patient goes in labour.

→ Induce labour at the 37th week of gestation is not the best course of action, as it is associated with high failure rate, which often leads to Caesarean delivery.
→ Schedule elective Caesarean delivery is considered unnecessary in patients who do not have diabetes. Statistics have shown no evidence that Caesarean delivery reduces the rate of complications.
→ Serial ultrasound for fetal weight estimation is incorrect. The strategies used to predict fetal macrosomia are risk factors, Leopold’s manoeuvres, and ultrasonography. Even when they are combined, they are considered inaccurate; much less ultrasonography alone.
→ At this point, blood glucose control in pregnancies associated with diabetes seems to have desired results in preventing macrosomia- A weight loss program is usually not recommended- Instead, expectant management should be considered.

The best antibiotic of choice for empirical treatment of a urinary tract infection (UTI) during pregnancy is cephalexin. Nitrofurantoin and amoxicillin-clavulanate are second and third in-line respectively.
Patients allergic to penicillin, which is manifested as a rash can also be safely treated with cephalexin. But cephalosporins are not recommended if the presentation of allergic reaction to penicillin was anaphylactic, instead they should be treated with nitrofurantoin.

NOTE– Asymptomatic bacteriuria, such as >10 to power of 5 colony count in urine culture of an asymptomatic woman in pregnancy, should best be treated with a one week course of antibiotics, followed by confirming the resolution of infection via a urine culture repeated 48 hours after the completion of treatment.

Amoxicillin without clavulanate is recommended only in cases were the susceptibility of the organism is proven.

Macrolides like clarithromycin are usually not recommended for the treatment of UTI.

Aminoglycosides are coming under category D drugs should be avoided during pregnancy, unless there is a severe indication of gram negative sepsis.

Tetracycline, due to their potential teratogenic effects, are contraindicated in pregnancy.

Between 18-20 weeks of gestation is the best time to perform an ultrasound for the identification of any physical or anatomical abnormalities including neural tube defects.

Maternal serum screening for Down syndrome is best performed between 15-17 weeks of pregnancy and this screening includes analysis of alpha fetoprotein, estriol, and beta-HCG in maternal blood. Conducting tests on accurate dates is necessary to obtain reliable results.

Amniocentesis which is very accurate for the diagnosis of chromosomal anomalies including Down syndrome, is best performed between 16-18 weeks of gestation and it carries a risk of 1 in 200 for miscarriage. Rh negative women will need Rh D immunoglobulin (anti-D).

Chorionic villus sampling is best performed between 10-12 weeks of gestation and carries a 1 in 100 risk of miscarriage, this test is also very much accurate for diagnosis of chromosomal anomalies. Rh negative women need Rh D immunoglobulin (anti-D).

It is best to perform rubella screen before conception than during pregnancy, this is because rubella vaccine is not recommended to be given to a pregnant mother as its a live vaccine.

This is a patient that recently gave birth and is still breastfeeding presenting with dyspareunia. The most likely cause would be a thin atrophic vaginal epithelium. This is very common presentation and is due to the low oestrogen levels due to the prolactin elevation from breastfeeding.

An unrecognised and unsutured vaginal tear should have healed by this time and should not be causing issues.

Endometriosis tends to resolve during a pregnancy, but if this was the issue, it would have caused dyspareunia prior to pregnancy.

Vaginal infective causes of dyspareunia, such as monilial or trichomonal infections, are rare in amenorrhoeic women.

Gas gangrene is synonymous with myonecrosis and is a highly lethal infection of deep soft tissue, caused by Clostridium species, with Clostridium perfringens being the most common. This organism has also had increased incidence as the cause of deep tissue infections associated with childbirth and infections after gynaecologic procedures including septic abortions, which can cause gas gangrene of the uterus.
Health care workers should suspect gas gangrene if anaerobic gram-positive bacilli are present in a wound with necrosis of soft tissue and muscle. The organisms produce a gas identifiable on x-ray or CT scans.
Patients with gas gangrene (myonecrosis) present with signs of infection such as fever, chills, pain, and less superficial inflammation at the site of infection than one would expect given the deep penetrating nature of these infections. The condition of the patient can rapidly progress to sepsis and death if not treated aggressively. The wound discharge is often dishwater looking with a musty order.

Breakthrough bleeding, breast tenderness, nausea, bloating, amenorrhea, hypertension, venous thromboembolic disease, increased risk of cervical cancer with decreased risk of ovarian & endometrial cancer, liver disorders like hepatic adenoma and increase in triglycerides due to estrogen component are the common side effects & risks of using combination oral contraceptives.

Patient in the given case mentioned symptoms of primary dysmenorrhea, which is recurrent lower abdominal pain associated with menstruation. Combination estrogen-progestin oral contraceptive pills (OCPs) are considered as the first-line treatment for dysmenorrhea in sexually active patients as OCPs help to reduce pain by thinning the endometrial lining, reducing prostaglandin release and by decreasing uterine contractions.
Nausea, bloating and breast tenderness, are considered as the early side effects of OCPs and will usually improve with continued use. The most common side effect is breakthrough bleeding which is usually associated with lower estrogen doses and other adverse effects caused by the pills include hypertension, increased risk of cervical cancer and venous thromboembolism. Although common perception considers weight gain as a side effect, several studies have shown that no significant weight gain is associated with OCPs, particularly with low-dose formulations.  Considering this, the patient should be reassured that her weight gain is not associated with regular use of OCPs.

In patients who are not sexually active, nonsteroidal anti-inflammatory drugs are considered as the first-line treatment for primary dysmenorrhea. As stopping contraception will increase this Patient’s risk of unintended pregnancy this is not advisable to her.

Switching the patient to a copper intrauterine device (IUD) will decrease systemic side effects, but as its inflammatory reaction in the uterus may increase pain symptoms, copper IUD is not recommended for patients with dysmenorrhea.

As Medroxyprogesterone will increase body fat and decrease lean muscle mass resulting in weight gain is not a good option for this patient. Also medroxyprogesterone due to its risk of significant loss of bone mineral density, is not recommended for adolescents or young women. So it can be used in this age group only if other options are unacceptable.

Presence of estrogen component is the main reason behind the side effects of combination OCPs. Progesterone-only pills have relatively fewer side effects but as they do not inhibit ovulation, they are less effective for treating dysmenorrhea and for contraception.

Combination oral contraceptive pills are the first-line therapy for primary dysmenorrhea in sexually active patients.  Its side effects include breakthrough bleeding, hypertension, and increased risk of venous thromboembolism. Researches proves that weight gain is usually not an adverse effect of OCPs.

Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Bacterial vaginosis is a condition caused by an overgrowth of normal vaginal flora. Most commonly, this presents clinically with increased vaginal discharge that has a fish-like odour. The discharge itself is typically thin and either grey or white.

Although bacterial vaginosis is not considered a sexually transmitted infection, women have an increased risk of acquiring other sexually transmitted infections (STI), and pregnant women have an increased risk of early delivery.

Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term.

BV recurrence rates are high, approximately 80% three months after effective treatment.

The effects of smoking on the outcomes of pregnancy are well documented and include an increased risk of preterm premature rupture of the membranes (PPROM), preterm birth, low birth weight, placenta previa, and placental abruption. Many studies have shown that the risk of Sudden Infant Death Syndrome (SIDS) is increased by maternal smoking during pregnancy.

Routine ultrasonography at around 18-22 weeks gestation has become the standard of care in many communities. Acceptance is based on many factors, including patient preference, medical-legal pressure, and the perceived benefit by physicians. However, rigorous testing has found little scientific benefit for, or harm from, routine screening ultrasonography.

The woman is most probably suffering from eclampsia.
Magnesium sulphate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.

This woman has signs and symptoms suggestive of cervical insufficiency, whose clinical features include pelvic pressure, premenstrual-like cramping and backache with increased vaginal discharge. Usually these symptoms will persist for several days to weeks.
Cervical insufficiency is seen between 14 – 20 weeks of gestation, which is presented as soft effaced cervix, with minimal dilation on physical examination and a 4 cm dilated and more than 80% effaced cervix will be the clinical presentation in a more advanced case.

Placental abruption presents with painful vaginal bleeding, whereas Placenta Previa presents as painless vaginal bleeding. Both cases will lead to shock but will not show any features of cervical insufficiency.

Anaemia, polyhydramnios, large for gestational age uterus and severe hyperemesis gravidarum are the commonly associated symptoms of a twin pregnancies.

New menstrual cycle after an abortion is expected to be presented with cervical dilation however signs of effacement will not be present along with it.

This patient is presenting with a low-lying placenta at 18 weeks of gestation. This is a common finding on ultrasound at 18-20 weeks. If there is not bleeding, there is an 80-90% chance that by late pregnancy, the placenta will have moved and is no longer occupying the lower uterine segment. For this reason, the repeat ultrasound examination is usually performed at 32-34 weeks of gestation. Further discussions about management can then be made after obtaining those results.

Leaving the repeat ultrasound until term would be inappropriate as intervention would be needed prior. If the placenta praevia is still present, it is typically advisable to deliver prior to term.

Cardiotocographic (CT) fetal heart rate monitoring is not required in the absence of bleeding or other symptoms.

Delivery by Caesarean section would not be necessary if the placenta was no longer praevia by the time the repeat ultrasound is done.

Repeat ultrasound examination at 22 weeks of gestation would also unnecessary and inappropriate as it is too close in time for the change to occur.

These are the six routine blood tests that every mum-to-be has to undergo around week 7 of pregnancy: Full Blood Count, Blood Typing, Hepatitis B Screening, Syphilis Screening, HIV Screening and Oral Glucose Tolerance Test (OGTT)

Nuchal translucency scans and maternal screening tests simply aid in determining a risk percentage for the presence of Trisomy 21, but an accurate diagnosis cannot be reached.

Chorionic villous biopsy (CVB), amniocentesis, and cordocentesis, are all prenatal diagnostic tests that can provide a definitive diagnosis regarding the presence of foetal abnormalities.

Amniocentesis performed at 16 weeks of gestation is associated with the lowest risk for miscarriage and hence is the safest test and should be recommended to the mother (correct answer).

The miscarriage risk from a CVB is at least double the risk following amniocentesis.

Nowadays, cordocentesis is rarely used for sampling of foetal material to detect chromosomal abnormalities as the test poses an even higher risk of miscarriage compared to the other procedures discussed above.

This patient who is at her 29 weeks of pregnancy, presented with sudden gush of clear fluid and Speculum examination has confirmed premature rupture of membrane (PROM).

Approximately, 50% of PROM progress to labour within 24 hours and in the remaining, 80% within seven days. The most important next step of management in this case is transferring this patient to tertiary care hospital as soon as possible. It is equally important to give corticosteroid therapy, like Betamethasone, if delivery prior to 34 weeks is likely to occur, as it will help in fetal lung maturity.

Cardiotocography (CTG) is usually not available in general practice settings and it can be done only while in the hospital. If CTG shows any abnormality or if there is any presence of infection it is better to induce labor.

Salbutamol and nifedipine are of no use in this case, as the patient is not in labour and does not require tocolytics.

There is evidence that folic acid, iodine and vitamin D are important for reproductive outcomes. Folic acid and iodine supplementation is recommended for women planning to conceive and in pregnancy.

The recommended dose of folic acid for women without special considerations planning to conceive is 400-500 mcg. The recommended dose of folic acid for women with special considerations is 2-5 mg per day.

Women planning a pregnancy, including those with thyroid disease, should take iodine supplements in the dose of 150 mcg per day prior to and during pregnancy.